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Review Article the Investigation and Management of Adenomyosis in Women Who Wish to Improve Or Preserve Fertility

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Review Article the Investigation and Management of Adenomyosis in Women Who Wish to Improve Or Preserve Fertility Hindawi BioMed Research International Volume 2018, Article ID 6832685, 12 pages https://doi.org/10.1155/2018/6832685 Review Article The Investigation and Management of Adenomyosis in Women Who Wish to Improve or Preserve Fertility Jin-Jiao Li,1 Jacqueline P. W. Chung,2 Sha Wang,1 Tin-Chiu Li,2 and Hua Duan 1 Department of Gynecology Minimally Invasive Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing , China Department of Obstetrics & Gynaecology, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong Correspondence should be addressed to Hua Duan; [email protected] Received 9 August 2017; Accepted 18 January 2018; Published 15 March 2018 AcademicEditor:WilliamH.Catherino Copyright © 2018 Jin-Jiao Li et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Te management of adenomyosis remains a great challenge to practicing gynaecologists. Until recently, hysterectomy has been the only defnitive treatment in women who have completed child bearing. A number of nonsurgical and minimally invasive, fertility- sparing surgical treatment options have recently been developed. Tis review focuses on three aspects of management, namely, (1) newly introduced nonsurgical treatments; (2) management strategies of reproductive failures associated with adenomyosis; and (3) surgical approaches to the management of cystic adenomyoma. 1. Introduction endometrial implants are found within the myometrium of the uterus. Te most common and widely accepted theory Adenomyosis is a common benign gynaecological condition involves the downward invagination of the endometrial but its diagnosis and treatment remain a clinical challenge to basalis layer into the myometrium due to either myometrial physicians. Te true incidence of adenomyosis is unknown and the prevalence varies widely due to the lack of a weakness or altered immunologic activity leading to standardized defnition and diagnostic criteria. Te preva- disruption of the endometrial-myometrial interface, also lence from previous retrospective cohort and prospective known as the “junctional zone (JZ)” [12]. Leyendecker et cohort observational studies is summarized in Tables 1 and al. [13] showed that uterine auto-traumatisation and the 2 [1–9]. Adenomyosis also commonly occurs together with initiation of the mechanism of tissue injury and repair endometriosis. Di Donato et al. [10] showed a prevalence of (TIAR) as the primary cause for adenomyosis development 21.8% in women undergoing surgery for endometriosis. Tey based on their method of “visualization” by transvaginal also showed an association with parous women, increasing ultrasound (TVS) and cinematographic magnetic resonance age, dysmenorrhea intensity, and presence of deep infltrating imaging (MRI). Teir group showed the archimetral endometriosis. compression from the neometral contraction at the onset Adenomyosis is best defned by Bird in 1972 as “the of menstruation causes high intrauterine pressure, leading benign invasion of endometrium into the myometrium, to rupture of the archimyometrium at cornual angles. Tus, producing a difusely enlarged uterus which microscopically fragments of the basal endometrium are then detached and exhibits ectopic non-neoplastic, endometrial glands and deposited into the myometrial wall where they develop into stroma surrounded by the hypertrophic and hyperplastic endometriotic cysts. In addition, as the basal stromal cells myometrium” [11]. at the fundo-cornual raphe are chronically over stretched, it initiates the TIAR mechanism and development of an 2. Pathogenesis adenomyoma. Other theories include de novo development from embryonic-misplaced pluripotent Mullerian remnants Te exact pathogenesis of adenomyosis remains debatable. or invagination along the intramyometrial lymphatic system Tediagnosisofadenomyosisismadewhenectopic or displaced bone marrow stem cells [14]. 2 BioMed Research International Table 1: Prevalence of adenomyosis afer hysterectomy specimens for various gynaecological conditions (from retrospective cohort studies). Vercellini et al. Vavilis et al. Seidman and Parazzini et al. Bergholt et al. Study 1995 [1] 1997 [2] Kjerulf1996 [3] 1997 [4] 2001 [5] Number of cases (�)1334 594 1252 707 549 Adenomyosis (%) 25 20 12–58 21 10–18 Uterine fbroid 23 21 15 Genital prolapse 26 26 30 Ovarian cyst 21 18 30 Cervical cancer 19 18 25 Endometrial cancer 28 16 Ovarian cancer 28 21 3. Diagnosis women between 40 and 50 years of age [14]. Heavy menstrual bleeding is present in up to 40–60% of patients, which may be Histologicalexaminationisthegoldstandardinthediagnosis due to the enlarged endometrial surface area or the increased of adenomyosis, even though the exact histological criteria vascularity of the endometrium [14]. Dysmenorrhea occurs have not been universally agreed. One accepted criterion is in 15–30% of patients, which may be related to the swelling the presence of endometrial tissue more than 2.5 mm below of endometrial tissue within the myometrium or increased the endomyometrial junction or a JZ thickness of more than production of prostaglandin within the myometrium [18]. 12 mm [15]. Te modifcation of the uterine structure may Both the amount of bleeding and degree of pain were range from thickening of the JZ of >12 mm to nodular or showntobesignifcantlycorrelatedwiththedegreeof difuse lesions involving the entire uterus. Tus, adenomyosis myometrial invasion [18]. Other presenting features include is classifed to “difuse adenomyosis” where endometrial chronic pelvic pain, dyspareunia, and the fnding of an deposits are found dispersed within the myometrium or enlarged uterus in an asymptomatic subject. Women with “focal adenomyoma” where the endometrial deposits are adenomyosis had been shown to have a decreased quality of more localized at one site within the uterine wall as a confned life [19], up to 33% of patients may be asymptomatic, and the lesion [14]. diagnosis of up to 30% of patients was only made by histology Apartfromthefndingsoftheseectopicendometrial following a hysterectomy [20]. tissues within the myometrium, smooth muscle changes Tere is also increasing evidence to show an association like hyperplasia are ofen found. Ultrastructural diferences between infertility and adenomyosis [21]. Several mecha- between smooth muscle cells from adenomyosis and normal nisms may be involved, including impairment of sperm uterus were found with myocytes showing cellular hypertro- transport [7], aberrant uterine contractility [22], alterations phy, diferences in cytoplasmic organelles, nuclear structures, of adhesion molecules, cell proliferation, apoptosis, and free and intercellular junctions [15]. Te myocytes in adenomyosis radical metabolism [15, 23]. Adenomyosis is also speculated also lack the cyclical changes present in myocytes of the to be a cause of recurrent implantation failure during IVF normal uterus [16]. treatment [24]. 4. Cystic Adenomyoma 6. Investigation Rarely, adenomyosis may present as a cystic lesion lined .. Two-Dimensional Ultrasound (USG). Two-dimensional with endometrial tissue and surrounded by myometrial tissue when it is called “cystic adenomyoma.” Juvenile cystic (2D) transabdominal USG may reveal uterine enlargement adenomyoma (JCA) is a subgroup of cystic adenomyoma that or asymmetric thickening of the anterior and posterior commonly occurs in adolescents or women < 30 years of age myometrial walls. However, transabdominal USG is ofen and is not associated with difuse adenomyosis. Takeuchi et not accurate enough in diagnosing adenomyosis as it fails al. [17] proposed the following diagnostic features of juvenile to provide sufcient image resolution for visualization of the cystic adenomyoma (JCA): (1) age < 30 years; (2) cystic myometrium. Terefore, 2D transvaginal USG is ofen the lesion of >1 cm in diameter independent of the uterine lumen frst-line investigation. In a review performed by Reinhold and covered by hypertrophic myometrium on diagnostic et al., it was shown that transvaginal USG had a sensitivity images; and (3) association with severe dysmenorrhea. Tey of 80–86%, specifcity of 50–96%, and an overall accuracy of found that laparoscopic excision of the lesion demonstrated 68–86% in diagnosing difuse adenomyosis [25]. signifcant improvement of dysmenorrhea in these cases. USG features of adenomyosis include the presence of three or more sonographic criteria: heterogeneity, increased 5. Presentations echogenicity, decreased echogenicity, and anechoic lacunae or myometrial cysts [26]. In contrast to uterine fbroids, Te classic presentation of adenomyosis is heavy, painful adenomyoma has a more elliptical shaped lesion with poorly menstrual bleeding, typically occurring in multiparous defned borders, no calcifcations, or edge shadowing. In BioMed Research International Table 2: Prevalence of adenomyosis from previous prospective cohort observational studies. Number of Diagnostic Study Study characteristics Defnition of adenomyosis Prevalence% patients (�) modality Focal adenomyoma: ill-defned lesions within the de Souza et al. 1995 Infertility patients presenting with dysmenorrhea or 26 MRI myometrium 54 [6] menorrhagia, all had laparoscopy performed Difuse adenomyosis: difuse or irregular JZ thickening Study group (� = 160): infertility patients with laparoscopy done showing endometriosis Focal adenomyoma: expansions
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